Over the past decade, patient safety has emerged as a major issue in hospitals, arising
from reports of unacceptable levels of harm to patients caused by the process of health
care itself rather than any underlying disease. A growing research movement has
developed around finding out why so much harm occurs, and what can be done to
reduce it. The ever-increasing complexity of health care provision is consistently cited
as an underlying factor, and alongside calls for more accountability and transparency,
formal systems of accountability such as guidelines and incident reporting have
emerged in response, designed to govern frontline activities and to manage complexity
through standardisation. As popular as these approaches are however, they are also
controversial, and a large subset of patient safety research is focused on identifying and
overcoming local ‘barriers’ to their implementation.
In this thesis, I analyse the problematic implementation of this formal accountability
and challenge its assumptions. I propose that we insufficiently understand how safety is
currently practiced by clinicians, and likewise, how accountability is practiced. My
thesis therefore focuses on exploring safety and accountability as practices. I describe
accountability not only in formal terms, but also as informal and everyday talk and
behaviour. Furthermore, I propose that the problems of implementation described above
can be reframed instead as tensions between accountabilities. In this study therefore, I
examine how clinicians negotiate multiple accountabilities in their practices of safety.
With a multidisciplinary group of 72 clinicians in a children’s hospital in New South
Wales, Australia, I created ethnographic data through observations, field interviews and
feedback sessions in two phases of field work, over ten months in total. Following each
phase, data were iteratively coded and analysed using a grounded theory approach.
With these data, I show how clinicians are enacting safety through their practices of
accountability, in contexts complicated by multiple accountabilities and multiple
meanings of safety. I show how clinicians inevitably produce accounts that are partial
and ‘incomplete’, at risk of becoming problematically disembedded from complexity. I
also show how clinicians are re-embedding these partial accounts, by engaging in
accountability practices that foreground multiplicity, diversity and reciprocity. I argue
that if we wish for practices of accountability to reflect and support clinical practices
that we see as complex and interconnected, then we need to embrace more complex and
interconnecting practices of accountability. Rather than calling for more accountability,
we need to practice more accountabilities instead, to increase the reciprocal and
reflexive engagement of participants with one another in (and beyond) the health care
system. In doing so, we would enable care that is ‘safer’ by enabling more people to
participate more variously and directly in negotiating the complexity and shifting
boundaries of health care delivery.

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Accountability and patient safety : a study of mess and multiplicities